Hyaluronidase is the name of a family of naturally occurring enzymes found in our tissues and produced by our bodies to break down hyaluronic acid. Hyaluronic acid is a large molecule composed of smaller molecules linked together: different types of hyaluronidases break down different bonds in the large molecule or are found in different body tissues. When you read or hear of “cross-linked hyaluronic acid” in dermal fillers, it means that unlike the natural occurring hyaluronic acid, the smaller molecules are bond together with added chemical bridges: this makes it more difficult for our body to get rid of it, making the product last longer in the skin.
What is hyaluronidase used for?
While hyaluronidase applications go from ophthalmic surgery to subcutaneous infusion therapy, this enzyme is getting known among the public because of its use in cosmetic medicine to dissolve hyaluronic acid fillers; such use is currently an off-label application of this drug.
In cosmetic medicine it is generally used to treat severe complications associated with hyaluronic acid filler injections such as tissue necrosis and blindness, or to treat bad cosmetic outcomes such as lumps and bumps; lately, hyaluronidase treatment is being requested by social media influencers to reverse the good and sought-after effects of hyaluronic acid fillers, in an effort to promote natural look and self-confidence. Lastly, hyaluronidase may be needed when the filler is misplaced or when there is migration of the HA product which, at least to some extent, is to be expected as time goes by.
Vitrase vs Hylenex vs Hyalase vs Hydase
While there are a few differences among hyaluronidase preparations, none is more or less effective than the other when it comes to dissolving fillers.
- Vitrase is the first that came to the market and is an ovine derived highly purified enzyme, meaning it comes from sheep. It’s available in vials with a strength of 200 units per mL.
- Hylenex is a human recombinant enzyme with a strength of 150 units per mL.
- Hydase is a bovine derived purified enzyme with a strength of 150 units per mL.
- Hyalase is a purified and standardized preparation coming in powder form that needs to be dissolved in sterile water; each ampoule contains 1500 units and its strength per mL depends on the dilution by the practitioner. It is available in the UK and Australia.
There is no difference in effectiveness among the different available forms of pharmaceutical hyaluronidase so your main concern should be about selecting an experienced provider and not about which drug is going to be used.
How to dissolve dermal fillers?
The answer to this question is “it depends” and as of today nobody knows for sure what approach is the best. The only type of dermal fillers that can be dissolved are hyaluronic acid fillers.
There is no real consensus or protocol to follow for this treatment.
Hyaluronidase should be injected in the same plane the filler was injected to (ie. At the same depth). It has an immediate effect and a very short half-life (2 minutes), meaning it is cleared from the tissues very quickly; its effects though last longer, about 24 to 48 hours.
Different HA filler preparations react differently to hyaluronidase because of their intrinsic characteristics: the more cross-linked a filler is and the greater the amount injected in the skin, the more units you will need to get rid of it. Since there are no guidelines on how to dissolve fillers with hyaluronidase, each practitioner may use a different approach. When there is no severe complication from hyaluronic acid fillers but a simple will to get back to a natural look, the best approach may be to undergo multiple treatment sessions with a relatively low dose of hyaluronidase, rather than a single high-dose injection. Many support this “less is more” approach with 5-15 units per injections site and a second treatment session 2 weeks after the first if necessary; this approach also decreases the severity of complications from hyaluronidase treatment and decreases the likelihood of severe allergic reactions to it.
Most aesthetic practitioners will have little experience with dissolving fillers, so if you want to reverse the cosmetic effects of a hyaluronic acid dermal filler the best advice is to look for a physician with experience in this specific area. Without experience, they would otherwise be guessing how to administer the hyaluronidase (how many units, what injection sites, how many sessions, etc.).
Will hyaluronidase destroy my face?
Hyaluronidase is not a “smart” drug, it can’t differentiate between the hyaluronic acid produced by your own body and the one injected by your practitioner, so it will have an effect on all hyaluronic acid it comes in contact with. Yes, it will degrade your own HA, but while you may look a bit puckered or hollow where hyaluronidase was injected right after treatment, there is a consensus among practitioners that this effect will be reversed within 24-48 hours, as your body restores the loss HA.
If you search online on popular cosmetic surgery websites where patients can review treatments, you will find a large number of negative reviews about hyaluronidase, with patients complaining of a very bad cosmetic outcome following its injection and trying to discourage others from pursuing such treatment. This does not seem to be true and supporting the physicians’ consensus there are several papers estimating the half-life and turnover of naturally occurring hyaluronic acid in the skin to be 24 hours, meaning that your own HA is degraded and re-synthetized every day!
So why do so many people complain about hyaluronidase having destroyed their face? Well multiple explanations come to my mind and letting aside the financial interest of dermal filler producers the most likely is that after many years looking one way you get used to it and by suddenly reversing your look to your original state you may not recognize yourself. Some degree of sagging may be possible as well, depending on how overfilled you were in the first place: think of it like the abdomen of a pregnant woman, after delivery it takes a while for the skin to tighten back up. You may want to ask your treating physician for advice on how to speed up that process, which may include performing one of many possible non-invasive treatments like High Intensity Focused Ultrasound (HIFU) and RadioFrequency (RF) or the use of cosmeceuticals.
Hyaluronidase will not dissolve or break-down any molecule other than hyaluronic acid, so don’t worry about your collagen, subcutaneous fat, elastin etc.
Are there possible side effects or complications of using hyaluronidase?
Bruising and swelling are common after treatment but subside in a few days and should not cause concern.
Localized allergic reactions occur in around 0.1% of cases, while anaphylaxis is rare but still possible. If you have history of anaphylaxis or hypersensitivity reactions to insect bites you should stay in observation for 60 minutes after treatment as you may be at increased risk of this complication.
Is there any natural way to dissolve dermal fillers faster?
Besides hyaluronidase which is a naturally occurring enzyme in our own tissues, there is no other way of speeding up the dissolution of dermal fillers.
Some may advise to massage the area daily and this may help a little in two ways:
- It may flatten the area where the filler was injected by spreading it in the surrounding tissues.
- By increasing the blood flow in the area, this may increase the rate at which the filler is broken down and eliminated.
Don’t expect major improvements, but a gentle massage won’t hurt, although it may make it trickier to treat the area with hyaluronidase due to the possible migration of the filler from the original site of injection.
Always consult your specialist for advice tailored to your characteristics.
Can I get filler again in the area treated with hyaluronidase?
Sure, you can! Although more research is needed to better understand how long do dermal fillers really last, this may become the new normal in aesthetic medicine: first erasing all previous work and then treating again to avoid placing filler over filler. According to a research paper (on animal models), you can reinject fillers as soon as 6 hours after treatment with hyaluronidase, but most practitioners would likely advise for a longer waiting period of about 2 weeks: while the effect of hyaluronidase in the skin may end already 6 hours after the administration, its action may cause swelling, temporary loss of volume, bruising and other minor complications; for this reason it may be best to wait longer, until fully healed and until the final results from hyaluronidase treatment are visible, in order to have the optimal conditions for the dermal filler injection and achieve the most favorable aesthetic result.
- This month’s guideline: The Use of Hyaluronidase in Aesthetic Practice (v2.4)
M King – Journal of Clinical and Aesthetic Dermatology, Jun 2018
PMC Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6011868/
- The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers.
M Cavallini – Aesthetic Surgery Journal, Nov 2013
- Changing role of hyaluronidase in plastic surgery.
SH Bailey – Plastic and Reconstructive Surgery, Feb 2014
- Hyaluronidase: An overview of its properties, applications, and side effects.
HW Jung – Archives of Plastic Surgery, Jul 2020
- The duration of hyaluronidase and optimal timing of hyaluronic acid (HA) filler reinjection after hyaluronidase injection.
HJ Kim – Journal of Cosmetic and Laser Therapy, Dec 2017
- Hyaluronic Acid in the Third Millennium.
A Fallacara – Polymers, Jul 2018
- Hyaluronic acid: A key molecule in skin aging.
E Papakonstantinou – Dermatoendocrinology, Jul 2012
- Hyaluronan: its nature, distribution, functions and turnover.
JR Fraser – Journal of Internal Medicine, Jul 1997